H.D. chalke Brownlee, commenting on the rise and fall of epidemics, thought that germs may undergo mutation and that the generation of an epidemic depended on the right mutation, corresponding with a suitable disposition of the population at risk. Today, can much more be said? Young in a signal contribution to medical literature(1815) showed how the phthisis mortality varied in different parts of Britain and in other countries There may be significance in the fact that the more isolated places--parts of Scotland. wales and Ireland- -do not a to have met tuberculosis in epidemic form until more than 1o0 years after urban England. The decline in en corre spondingly delayed. In places such as Nepal and Puerto Rico, tuberculosis is in epidemic form today. (The mass radiography of Gurkha soldiers reveals an incidence of 14 8 per 1, 0oo )Brownlee found that in Pembrokeshire a line could be drawn across the county, above it the tuber culosis rate was high, below it, low. In the north the people are Welsh of beran stock: those to the south are the descendants of the normans. The anthropological characters are still evident, the place-names and language are different. Mining(coal, lead, slate, etc. ) under-nourishment and tuberculous cattle,weighted the scales against the susceptible welsh In due course some influence comes into action, which Newsholme thought prevents the excessive tuberculosis which an adverse environment evokes. He cited Ireland, where housing improvements did not retard the rising phthisis mortality; for some time in the U.S. A. it remained excessive, despite better living conditions-a higherracialresistance had not yet been acquired, and as happened to many other races, the irish were not yet able to withstand the massive and repeated infection which beset them in urban life. The wider question of the origins, antiquity and recent incidence of tuberculosis in the several races of the Americas, New Zealand, Africa and eastern countries is of great interest, but it is too large and complex to be discussed here. More primitive peoples may be suffering from exposure to a new infection, or an old infection reintroduced, to which immunity has been lost. They are fortunate in having new methods of prevention and treatment to aid them, and in being able to take advantage of the experiences of those countries, which after centuries of struggle, are at last coming to terms with tuberculosis OTHER SOURCES OF INFORMATION Q Fortunately, there are sources of information ancillary to the statistical, which ay be sought in contemporary literature, biography and art: some of these have been mentioned already as the sole record of the position many centuries ago; others, of more modern times, must be reviewed in a little more detail, in particular literature-biography, autobiography and fiction--from the begin ning of the eighteenth century Shakespeare(died 1 616)was exceptionally well-informed on medical matters and it is difficult to find any great author, not a doctor, who so often refers to the healing art(Bucknill). His infrequent allusion to 'consumptionand the rare references to its classical symptoms are, therefore, pointers to the impact of this 3o6
H. D. Chalke Brownlee, commenting on the rise and fall ofepidemics, thought that germs may undergo mutation and that the generation of an epidemic depended on the right mutation, corresponding with a suitable disposition of the population at risk. Today, can much more be said? Young in a signal contribution to medical literature (I8I5) showed how the phthisis mortality varied in different parts of Britain and in other countries. There may be significance in the fact that the more isolated places-parts of Scotland, Wales and Ireland-do not appear to have met tuberculosis in epidemic form until more than ioo years after urban England. The decline in these countries has been correspondingly delayed. In places such as Nepal and Puerto Rico, tuberculosis is in epidemic form today. (The mass radiography of Gurkha soldiers reveals an incidence of I4-8 per i,ooo.) Brownlee found that in Pembrokeshire a line could be drawn across the county, above it the tuberculosis rate was high, below it, low. In the north the people are Welsh of Iberian stock; those to the south are the descendants of the Normans. The anthropological characters are still evident, the place-names and language are different. Mining (coal, lead, slate, etc.), under-nourishment and tuberculous cattle, weighted the scales against the susceptible Welsh. In due course some influence comes into action, which Newsholme thought prevents the excessive tuberculosis which an adverse environment evokes. He cited Ireland, where housing improvements did not retard the rising phthisis mortality; for some time in the U.S.A. it remained excessive, despite better living conditions-a higher racial resistance had not yet been acquired, and as happened to many other races, the Irish were not yet able to withstand the massive and repeated infection which beset them in urban life. The wider question of the origins, antiquity and recent incidence of tuberculosis in the several races of the Americas, New Zealand, Africa and eastern countries is of great interest, but it is too large and complex to be discussed here. More primitive peoples may be suffering from exposure to a new infection, or an old infection reintroduced, to which immunity has been lost. They are fortunate in having new methods of prevention and treatment to aid them, and in being able to take advantage of the experiences of those countries, which after centuries of struggle, are at last coming to terms with tuberculosis. OTHER SOURCES OF INFORMATION Fortunately, there are sources ofinformation ancillary to the statistical, which may be sought in contemporary literature, biography and art: some of these have been mentioned already as the sole record of the position many centuries ago; others, of more modern times, must be reviewed in a little more detail, in particular literature-biography, autobiography and fiction-from the beginning of the eighteenth century. Shakespeare (died I6I6) was exceptionally well-informed on medical matters and it is difficult to find any great author, not a doctor, who so often refers to the healing art (Bucknill). His infrequent allusion to 'consumption' and the rare references to its classical symptoms are, therefore, pointers to the impact of this 306
The Impact of T uberculosis on History, Literature and Art disease on the life of his times. This lends support to the view that it was not until after his death that the sharp rise in incidence began. It is true that wasting disease,,'phtisick'(phthisis), rotten lungs, wheezing lungs'and "lethargiesare spoken of in many of his plays, but the words seem to be applied indefinitely, relating to syphilis, ague and other conditions as well as to tuberculous disease a rascally phtisick so troubles me.. I have a rheum in such an ache ny bones -Troilus and Cressida. sumption sow in hollow bones of m I was told you were in consumption -Much Ado About Nothi Side stitches that shall pen thy breath up -The Tempest most incident to maidens. -The Winters Tale After 1700, novelists allude to symptoms and effects more often and descrip tions of the pale heroine languishing in a decline are not hard to find, but usually the writers avoided the dreaded word consumption. Consumptive children, said a writerina popular work of the nineties, are the novelists'favourite little heroes and heroines, who appear like fairies to gladden the hearts of parents and friends for a short season. Victorian song writers also liked them. It is only in the past few decades, as the stigma has slowly disappeared, that tuber culosis has been named with any frequence; nowadays no details are spared of the early symptoms, the rigours of sanatorium treatment, and the dramati episode of the sudden haemoptysis. E.g. The Plague and 1, Betty Macdonald The Print Petticoat, Lucilla Andrews; Three Comrades, Erich Remarque. Swift, in The Tale of a Tub (168g), does describe languishing consumption, whose tainted breath destroys unhappy infants; so does Fielding in Tom Jones (174o). Samuel Richardson, the author of the first English novel(I74o)makes Clarissa, in the book of that name, die of a decline, aged nineteen. Elaine in The Morte d'Arthur of Malory(14o)may well have been the first young lady of he English romance to have been so afflicted. The decline associated with the emotional disturbances of an unhappy love affair was a popular theme with Victorian novelists like the Brontes and Jane Austen, who were themselves tuberculous. You will remember Helen Burns in Jane Eyre(1847)who died of semi-starvation and neglected colds; and"the vanished bloom and wasted flesh n Shirley(1849), also written by Charlotte Bronte, about her sister. There were many more who faded like any fower in drought,. The closing scenes were ually happy, quite unlike those occurring in real life(there are no major crises in Jane Austens works and no deaths). In considering these characters, it is to be noted that many authorities today believe that emotional and mental upsets act as exciting causes of active tuberculosis, and Kissen and others peak of a break in the "love- link'in this connexion. One other youthful victim should be mentioned, poor Smike in Nicholas Nickleby, with sunken eyes too bright and hollow cheeks too flushed Smollet, who had no success as a doctor, wrote admirably, despite his ill- temper and vindictive nature: he had tuberculosis himself and wrote of it in many of his books. This passage is from Roderick Random(1748), about a sick parade at se one(sailor)complained of a pleuritic stitch and spitting of
The Impact of Tuberculosis on History, Literature and Art disease on the life of his times. This lends support to the view that it was not until after his death that the sharp rise in incidence began. It is true that 'wasting disease', 'phtisick' (phthisis), 'rotten lungs', 'wheezing lungs' and 'lethargies' are spoken of in many of his plays, but the words seem to be applied indefinitely, relating to syphilis, ague and other conditions as well as to tuberculous disease: ... a rascally phtisick so troubles me ... I have a rheum in my eye too, and such an ache in my bones.-Troilus and Cressida. Consumption sow in hollow bones of man.-Timon of Athens. I was told you were in consumption.-Much Ado About Nothing. Side stitches that shall pen thy breath up.-The Tempest. Pale primroses that die unmarried ... most incident to maidens.-The Winter's Tale. After I 700, novelists allude to symptoms and effects more often and descriptions of the pale heroine languishing in a decline are not hard to find, but usually the writers avoided the dreaded word 'consumption'. Consumptive children, said a writer in a popular work ofthe nineties, are the novelists' favourite little heroes and heroines, who appear like fairies to gladden the hearts ofparents and friends for a short season. Victorian song writers also liked them. It is only in the past few decades, as the stigma has slowly disappeared, that tuberculosis has been named with any frequence; nowadays no details are spared of the early symptoms, the rigours of sanatorium treatment, and the dramatic episode of the sudden haemoptysis. (E.g. The Plague and I, Betty Macdonald; The Print Petticoat, Lucilla Andrews; Three Comrades, Erich Remarque.) Swift, in The Tale of a Tub (I689), does describe languishing consumption, 'whose tainted breath destroys unhappy infants'; so does Fielding in Tom jones (I 740). Samuel Richardson, the author of the first English novel (I 740) makes Clarissa, in the book of that name, die of a decline, aged nineteen. Elaine in The Morte d'Arthur of Malory (1470) may well have been the first young lady of the English romance to have been so afflicted. The decline associated with the emotional disturbances of an unhappy love affair was a popular theme with Victorian novelists like the Brontes and Jane Austen, who were themselves tuberculous. You will remember Helen Burns in jane Eyre (I847) who died of semi-starvation and neglected colds; and 'the vanished bloom and wasted flesh' in Shirley (I849), also written by Charlotte Bronte, about her sister. There were many more who 'faded like any flower in drought'. The closing scenes were usually happy, quite unlike those occurring in real life (there are no major crises in Jane Austen's works and no deaths). In considering these characters, it is to be noted that many authorities today believe that emotional and mental upsets act as exciting causes of active tuberculosis, and Kissen and others speak of a break in the 'love-link' in this connexion. One other youthful victim should be mentioned, poor Smike in Nicholas Nickleby, 'with sunken eyes too bright and hollow cheeks too flushed'. Smollet, who had no success as a doctor, wrote admirably, despite his illtemper and vindictive nature: he had tuberculosis himself and wrote of it in many of his books. This passage is from Roderick Random (I748), about a sick parade at sea: '... one (sailor) complained of a pleuritic stitch and spitting of 307